The importance of proper weight, appropriate diet, and exercise in reducing heart disease risk is well established. How best to achieve those ends? In the scientific statement, Interventions to Promote Physical Activity and Dietary Lifestyle Change for Cardiovascular Risk Factor Reduction in Adults, the American Heart Association (AHA) offers evidence-based recommendations.1
“Primary-care practitioners [PCPs] are on the front line,” says Ralph Sacco, MD, professor and chairman of neurology at the University of Miami Miller School of Medicine and president of the AHA. “They see the people who are at risk; and even patients who have had specialist care for a heart attack or stroke will usually have follow-up care from their own PCP.”
Behavioral interventions ideally combine counseling and other support from the health professional with the patient’s self-monitoring and goal-setting efforts, according to the authors of the AHA statement.
“Awareness comes first,” says Dr. Sacco. “If you do not recognize that there is a problem, you won’t do anything about it.” Surveys consistently show that more people think they’re in good health than actually are, he says: PCPs should routinely measure weight and waist circumference, ask about diet and physical activity, and alert patients to areas that need improvement.
The AHA document advocates motivational interviewing, which aims to help people understand and resolve ambivalence about changing their behavior. For patients who have real difficulty in taking steps toward behavior change, referral to a counseling professional trained in motivational interviewing may be in order.
Evidence supports the importance of setting specific, realistic goals at the outset of treatment. Ideally, the authors say, these goals include readily achievable outcomes defined in behavioral (e.g., reducing intake of foods high in saturated fat) rather than physiological terms (e.g., reducing LDL). The former are under the patient’s more direct control and subject to his or her observation, the authors explain.
The PCP should help patients define goals that are “appropriately ambitious” in light of their capabilities. According to the AHA scientific statement, “Goals that are too difficult may not be attempted, whereas those viewed as too easy may not be taken seriously or provide a sense of satisfaction once achieved.”
Data have been inconsistent as to whether it is more effective to target several behaviors at once (e.g., increase physical activity at the same time as changing diet) or to approach them sequentially.
Based on Dr. Sacco’s experience, it is realistic to regard health behavior change as incremental. “I often find it useful to prioritize goals. When patients begin to see results with one, they are motivated to go on to the next.”
Self-monitoring, feedback, and reinforcement
A formal system for tracking behavior change has been shown to be a key element of effective programs to increase physical activity, and several recent trials of weight loss regimens found that participants who self-monitored lost twice the weight of those who did not.
Self-monitoring, by definition, relies on the patient’s own efforts, but the clinician can play a key role in suggesting specific strategies and techniques, even providing forms with which to track weight, food consumption, or time spent exercising. Ongoing engagement through such external prompts as telephone messages and e-mail reminders might also be considered. Electronic self-monitoring systems (including commercial and free Internet-based programs) were found effective in several studies.